Karam et al.

Journal of Orthopaedic Surgery and Research (2020) 15:100

https://doi.org/10.1186/s13018-020-01619-4

RESEARCH ARTICLE Open Access

Periprosthetic proximal femoral fractures in

cemented and uncemented stems
according to Vancouver classification:
observation of a new fracture pattern
James Karam*, Paul Campbell, Shivang Desai and Michael Hunter

Abstract
Background: Periprosthetic fractures are increasingly encountered in hip arthroplasty. The Vancouver classification
system is widely used. Little knowledge exists regarding the association of the Vancouver classification with either
cemented or uncemented stems. The aim was to analyse a series of fractures and determine associations.
Methods: A series of consecutive patients over 8 years was identified including only post-operative fractures of
primary hip arthroplasties. Baseline and radiographic characteristics were recorded including the type of stem
fixation (cemented or uncemented) and Vancouver classification. Statistical analysis was performed to determine
the association of the Vancouver classification between cemented and uncemented stems.
Results: A total of 172 patients were identified (84 cemented stems, 88 uncemented stems). There were 30
Vancouver A fractures (12 cemented vs.18 uncemented, p > 0.05), 125 Vancouver B fractures (63 cemented vs. 62
uncemented, p > 0.05) and 17 Vancouver C fractures (9 cemented vs. 8 uncemented, p > 0.05). The Vancouver B2
fracture occurred most frequently (N = 95; 44 cemented vs. 51 uncemented, p > 0.05) and consists of four distinct
fracture patterns: the previously described comminuted ‘burst’, clamshell and spiral patterns and the newly
observed ‘reverse’ clamshell. The burst and spiral fracture patterns are significantly associated with cemented stems,
and the clamshell pattern is significantly associated with uncemented stems.
Conclusions: Vancouver A, B and C fractures occur equally in cemented and uncemented stems. Awareness of four
distinct Vancouver B2 fracture patterns, including the newly observed reverse clamshell, will aid surgeons in
predicting stem instability.
Keywords: Hip, Arthoplasty, Periprosthetic, Fracture, Classification, Pattern

Background uncemented stems [3]. More commonly, fractures occur

Periprosthetic proximal femoral fractures are an increas-
ing problem in hip arthroplasty. The reported frequency is
3.5% at 20 years after primary implantation and is increas-
ing in conjunction with rising rates of arthroplasty [1, 2].
Fractures occur intraoperatively, often in association with
* Correspondence: jameseliaskaram@gmail.com
Gosford District Hospital, Central Coast Local Health District, Gosford, NSW
2250, Australia
postoperatively secondary to falls in a frail elderly popula-
tion. Despite international variations in the usage of
cemented and uncemented stems, there is no clear evi-
dence demonstrating an increased risk of fracture in one
stem type over the other [4–6]. The Vancouver classifica-
tion system of periprosthetic femoral fractures has widely
been adopted by surgeons [7] (Table 1) and has been
shown to be reliable [8–10].

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Karam et al. Journal of Orthopaedic Surgery and Research (2020) 15:100 Page 2 of 7

Table 1 Vancouver classification

Vancouver classification
Subtypes
A: fractures of the trochanteric
region; stem stable
AG: fracture of the greater trochanter
AL: fracture of the lesser trochanter
B: fractures around or just distal C: fractures well distal to
to the stem the stem; stem stable
B1: stem stable
B2: stem loose, good bone stock
B3: stem loose, poor bone stock

To date, no definitive relationship has been established
between fracture pattern according to the Vancouver
classification and stem type whether cemented or unce-
mented. In particular, it is unknown whether Vancouver
B2 fractures, denoting a loose stem, occur with greater
frequency in one stem type over the other. The primary
aim of this study was to determine the associations be-
tween fractures in cemented and uncemented stems and
the Vancouver classification. A secondary aim was to in-
vestigate differences in baseline characteristics between
patients sustaining periprosthetic fractures of both stem
types. The proposed utility of this study will be in adding
further knowledge to the nature of periprosthetic frac-
ture patterns in hip arthroplasty.
Methods
Ethics approval for the purpose of conducting a retro-
spective study was obtained from the local health district
institutional review board. A consecutive series of pa-
tients in a single hospital with periprosthetic proximal
fractures was identified through a search of a hospital
coding database over an 8-year period from February
2011 to February 2019. Only patients with periprosthetic
fractures of primary hip implants were included. Patients
with intraoperative fractures, fractures of revision hips
and interprosthetic fractures were excluded.
Data was recorded based on electronic documentation
and analysis of digital X-rays and computed tomography
scanning which was obtained in the majority of patients.
Baseline details recorded included age, gender, body mass
index and pre-morbid reduced mobility or carer depend-
ence. Operative details recorded included time in months
from primary implantation, indication for arthroplasty
(osteoarthritis or fracture), type of stem (cemented or
uncemented) and type of arthroplasty (total or hemiar-
throplasty). Radiographic details recorded included the
Vancouver classification, varus stem position and Dorr
classification. Stem geometry (tapered or composite beam
in cemented stems and straight or wedge in uncemented
stems) was also recorded based on radiographic appear-
ance. The determination of the Vancouver classification
was made based on radiographic appearance and intraop-
erative findings in patients who proceeded to surgery. As
an adjunct, a survey of plain film-only representative frac-
ture patterns from this series was conducted amongst
three orthopaedic surgeons affiliated with the study hos-
pital but not directly involved with the study.
Statistical analysis was performed using T tests for
continuous variables and Fisher’s exact test for categor-
ical variables to compare a cohort of patients with
cemented stems to a cohort of patients with uncemented
stems with respect to baseline characteristics and the
Vancouver classification. All tests were two-sided with a
significance level of 0.05. Statistical analysis was per-
formed using GraphPad Prism version 8.0.0 (GraphPad
Software, San Diego, CA, USA).
Results
Patient numbers
A total of 1181 patients were identified after querying
the hospital database. This number reflects the deliber-
ately broad inclusion of classification codes from the tro-
chanteric to midshaft anatomical regions to ensure
unlisted periprosthetic fractures were not missed. Nine
hundred seventy-eight patients with non-periprosthetic
proximal femoral fractures were excluded. Of the
remaining 203 patients, further exclusion was applied to
8 patients with intraoperative fractures, 6 patients with
periprosthetic fractures of revision implants and 17 pa-
tients with periprosthetic fractures of hip fixation de-
vices. After exclusions, a total of 172 patients were
included in the study. All fractures were sustained after
falls. Eighty-four fractures occurred in patients with
cemented femoral stems, and 88 fractures occurred in
patients with uncemented stems.
Baseline characteristics
A comparison of baseline characteristics of patients in
the cemented and uncemented groups is shown in
Table 2. Significant differences between groups were
identified with respect to age, time from initial im-
plantation, neck of femur fracture indication for
arthroplasty, primary hemiarthroplasty, varus stem
placement and body mass index. In particular, almost
half of the stems in the cemented group were im-
planted for fracture, the majority being hemiarthro-
plasties. There were no significant differences between
groups with respect to gender, Dorr classification and
pre-morbid reduced mobility or carer dependence.
The majority of cemented stems were of taper design
(74/84, 88.1%) with the remainder being of composite
Karam et al. Journal of Orthopaedic Surgery and Research (2020) 15:100 Page 3 of 7

Table 2 Baseline characteristics

Characteristic Cemented, N = 84 Uncemented, N = 88 p value
Mean age (years) 82.48 (SD 8.48, 95% CI 80.64–84.32, 78.23 (SD 9.57, 95%CI 76.70–80.76, 0.0073
range 60–102) range 40–98)
Gender (number/% male) 39/46.43% 47/53.41% 0.4457
Mean time from implant (months) 68.55 (SD 80.77, 95% CI 49.15-87.95, 124.41 (SD 104.60, 95% CI 99.04–149.73, 0.0006
range 1–432) range 1–552)
Mean Dorr ratio 0.52 (SD 0.08, 95% CI 0.50-0.53, 0.52 (SD 0.09, 95% CI 0.50–0.52, 0.9270
range 0.37–0.76) range 0.33–0.86)
Varus stem (number/%) 28/33.33% 17/19.32% 0.0393
Mean body mass index 24.15 (SD 5.32, 95% CI 22.83–25.48, 27 (SD 4.55, 95% CI 25.88–28.13, 0.0014
range 15.8–45.5) range 18–40)
Hemiarthroplasty (number/%) 17/20.24% 3/3.41% 0.0006
Neck of femur fracture indication (number/%) 37/44.05% 6/6.82% 0.0001
Dependence on walking aid/carer (number/%) 44/52.38% 41/46.59% 0.5419

beam design (10/84, 11.9%). In the uncemented
group, the majority of stems were of straight design
(61/88, 69.3%) with the remainder being wedge design
stems (27/88, 30.7%).
Vancouver classification
A comparison of the Vancouver classification of cemented
and uncemented stems is shown in Table 3. There were no
significant differences between cemented and uncemented
stems in their association with each Vancouver classifica-
tion subtype. Results of an adjunct survey of the plain film
only appearance of representative fracture patterns per-
formed by three orthopaedic surgeons indicated 100%
agreement in classifying Vancouver A and C fractures and
73.14% agreement in classifying Vancouver B fractures.
An additional observation of this study was that the
Vancouver B2 classification consists of four distinct frac-
ture patterns: the previously described comminuted
‘burst’, clamshell and spiral patterns and the newly ob-
served ‘reverse’ clamshell pattern. Description of these
fracture patterns follows in the “Discussion” section, and
representative X-ray appearances from this series are
shown with accompanying graphic depictions in Fig 1.
The comparative association of these fracture patterns
with each stem type is shown in Table 4. Burst and
Table 3 Vancouver classification in cemented and
uncemented stems
Vancouver Cemented, Uncemented,
classification N = 84 N = 88
A 12 18
B 63 62
B1 15 11
B2 44 51
B3 4 0
C 9 8 0.8012
spiral fracture patterns were significantly associated with
cemented stems whereas the clamshell fracture pattern
was significantly associated with uncemented stems. The
reverse clamshell pattern occurred similarly in both
stems. The association of Vancouver classification sub-
types including the four B2 fracture patterns listed above
with respect to stem geometry (Table 5) reflected the
overall trend of fracture patterns.
Discussion
To date, this is the largest study to directly compare
the relationship of periprosthetic fractures in cemen-
ted and uncemented stems to the Vancouver classifi-
cation. No significant differences were identified
between cemented or uncemented stems in their asso-
ciation with Vancouver A, B or C fractures. The Van-
couver B2 fracture occurred equally in both groups,
indicating an equal rate of stable and unstable stems
in periprosthetic fractures of both stems. Comparably,
Fenelon et al. performed an analysis of periprosthetic
fractures in cemented and uncemented stems [11].
Distinctly, a greater number of Vancouver B2 and B3
fractures were recorded in their significantly larger
cemented cohort.
The Vancouver B2 fracture accounted for the greatest
number of patients in either group in this study, a finding
consistent with multiple other series [12–14]. An observa-
tion of this study was that the B2 fracture consists of four
p value distinct patterns. Three have previously been described:
the comminuted ‘burst’, clamshell and spiral patterns.
0.3198 A highly comminuted ‘burst’ pattern in tapered cemen-
0.6080 ted stems with ‘splitting’ along the cement mantle, similar
0.2963 to an ‘axe’, was described by Phillips et al. [15]. Sup-
0.5399 porting their observation, this fracture was signifi-
0.1143
cantly associated with cemented stems in this study.
The highly comminuted nature of these fractures
raises concerns for bone devitalisation, and these
Karam et al. Journal of Orthopaedic Surgery and Research (2020) 15:100 Page 4 of 7

Table 4 Vancouver B2 fracture pattern in cemented and

uncemented stems
Fracture pattern Cemented, Uncemented, p value
N = 84 N = 88
Burst 18 2 < 0.0001
Clamshell 1 30 < 0.0001
Reverse clamshell 7 12 0.3336
Spiral 18 7 0.0165

fractures often require meticulous removal of cement

and bypassing with a distal bearing stem [16].
The ‘clamshell’ fracture was described by Capello et al.
[17] in association with uncemented stems, a finding
reflected in the results of this series. This fracture origi-
nates at the medial base of the greater trochanter and
extends to the medial cortex distal to the lesser trochan-
ter with the preservation of the lateral cortex. Widening
of the calcar region and subsidence of the stem are
radiographic markers of stem instability. Previous series
have shown this fracture to be significantly associated
with anatomical and wedge design uncemented stems
[18, 19], an association supported by this study.
Grammatopolous et al. described a spiral fracture pat-
tern in a series of periprosthetic fractures of cemented
stems, often in association with a separate wedge frag-
ment and significant comminution [20]. The significantly
greater number of spiral fractures in cemented stems in
this series may reflect the tendency for fractures around
a tubular cement mantle to propagate in a fashion simi-
lar to native bone.
In radiographically analysing a large series of peripros-
thetic fractures, a consistent fracture pattern not previ-
ously described in the literature was observed. This
fracture originates in the medial calcar and exits through
the lateral cortex with an intact medial cortex. This frac-
ture is named the ‘reverse’ clamshell pattern and is

Table 5 Vancouver classification including B2 fracture

pattern according to stem geometry (number and
percentage within group)
Cemented, N = 84 Uncemented, N = 88
Fracture pattern Composite Tapered, Wedge, Straight,
beam, N = 10 N = 74 N = 27 N = 61
A 1 (10%) 11 (14.9%) 4 (14.8%) 14 (23%)
B1 2 (20%) 13 (17.6%) 3 (11.1%) 8 (13.1%)
B2—burst 1 (10%) 17 (23%) 2 (7.4%) 0 (0%)
B2—clamshell 0 (0%) 1 (1.4%) 10 (37%) 20 (32.8%)
B2—reverse 0 (0%) 7 (9.5%) 5 (18.5%) 7 (11.5%)
clamshell
B2—spiral 4 (40%) 14 (18.9%) 3 (11.1%) 4 (6.6%)
Fig. 1 Vancouver B2 fracture patterns: 1.1 burst, 1.2 clamshell, 1.3
reverse clamshell, and 1.4 spiral B3 1 (10%) 3 (4.1%) 0 (0%) 0 (0%)
C 1 (10%) 8 (10.8%) 0 (0%) 8 (13.1%)
Karam et al. Journal of Orthopaedic Surgery and Research
recognised by this study as a commonly occurring Van-
couver B2 fracture pattern. This name was chosen for
two reasons: the first, that it is the mirror image of
the ‘clamshell’ and the second, that it behaves simi-
larly to a reverse oblique proximal femoral fracture,
with similar supero-lateral displacement of the prox-
imal fragment from abductor pull. This fracture oc-
curs similarly in cemented and uncemented stems,
and further radiographic examples from this series are
shown in Fig. 2. Although it was not the aim of this
study to investigate outcomes of treatment, reverse
clamshell fractures were routinely managed in this
series with revision arthroplasty to a distal bearing
stem with either cerclage wire or plate fixation of the
proximal fracture fragment. An example of a patient
treated with this approach is shown in Fig. 3 demon-
strating the achievement of union.
In this series, a similar number of Vancouver B1 frac-
tures occurred in both cemented and uncemented
stems. It was observed that B1 fractures in cemented
stems often occurred at the tip of the stem, and the in-
fluence of stem design and the cement mantle on frac-
tures in this region has previously been identified [21].
It is often challenging on plain films alone to determine
implant stability in undisplaced fractures of cemented
stems, and computed tomography is often helpful in
assessing the integrity of the cement mantle. Fracture
of the cement mantle implies a loose stem and hence a
B2 fracture. Keys to distinguishing between B1 and B2
fractures in uncemented stems include calcar widening,
new bone-implant interface gaps and stem subsidence.
Computed tomography scanning with metal artefact
reduction may aide determination of implant stability,
although this determination may only conclusively be
made intraoperatively.
A paucity of Vancouver B3 fractures was identified in
this series, and only in cemented stems. There is a vari-
able rate of incidence of Vancouver B3 fractures in
Fig. 2 Reverse clamshell fracture pattern. In these radiographs, further examples of the reverse clamshell fracture pattern are shown in both
cemented and uncemented stems displaying the typical fracture pattern involving the lateral cortex only with preservation of the medial cortex
(2020) 15:100 Page 5 of 7
published series, and identification of strict B3 patterns
may be subject to a high rate of inter-observer variability
[22]. Identification of osteolysis in the setting of fracture
is often a subjective assessment, particularly if prior X-
rays are not available and the patient is asymptomatic
prior to fracture [23]. A and C fractures occurred simi-
larly in both groups, and these fractures likely occur in-
dependently of stem fixation and design.
The Vancouver classification system is based on the
assessment of plain films alone. As intraoperative find-
ings in patients who proceeded to surgery were factored
into classification, formal validation of classification in
this study was not performed. Agreement rates of 80%
for this classification system have been published, with
the commonest cause for inter- and intra-observer
variability being distinguishing between Vancouver B
subtypes [24]. This is reflected in the adjunct survey per-
formed in this study.
It is not the intention of this study to propose a modi-
fication to the Vancouver classification system. This
study supports the use of the Vancouver system in the
classification of periprosthetic fractures. Regardless of
fracture pattern, a B2 fracture denotes a loose stem.
Each fracture pattern, including the reverse clamshell, is
approached with similar principles and centred on im-
plant stability. Although revision arthroplasty is conven-
tionally indicated where the stem is loose, there is an
increasing weight of evidence to support fixation alone
in B2 fractures [25, 26].
Although a large and comparable number of patients
in both cemented and uncemented groups support the
observations made in this study, there were significant
differences in baseline characteristics between groups.
Fractures in the uncemented group occurred twice as
long a period after implantation as the cemented group.
This is likely explained by the uncemented cohort re-
ceiving arthroplasty at a younger age and is supported
by registry data demonstrating high 10-year implant
Karam et al. Journal of Orthopaedic Surgery and Research (2020) 15:100
Fig. 3 Surgical management of reverse clamshell fracture with
revision arthroplasty and cerclage wire fixation
survival rates for uncemented implants [27] and a long-
term series of uncemented stems demonstrating cumula-
tive probability of fracture of 1.6% at 10 years increasing
to 13.2% at 29 years after surgery [28]. The lower time
from implantation of the cemented group is likely ex-
plained by the significantly greater number of patients in
this group receiving arthroplasty including hemiarthro-
plasty for neck of femur fractures accounting for almost
half of the cohort. This reflects the frailty of this popula-
tion with a significantly higher age than the uncemented
group. This may also explain the lower body mass index
in the cemented cohort. The overall frailty of patients
sustaining periprosthetic fractures is suggested by the
surrogate markers of reduced mobility and carer de-
pendence accounting for a high percentage of patients in
both groups. Although a greater number of stems in the
cemented cohort were placed in varus, an increased risk
of fracture in varus stems has not been demonstrated in
either stem type in previous studies [29, 30].
This study was limited by its retrospective design. Data
collection from a single hospital limits the generalisabil-
ity of results. The inclusion of patients who received
arthroplasty for fracture introduced significant hetero-
geneity into the study population. This may have caused
bias in the recording of fracture patterns in the cemen-
ted cohort of whom almost half received arthroplasty for
fracture. Patients who sustain neck of femur fractures
often have weaker osteoporotic bone, and the relation-
ship of this to descriptive periprosthetic fracture patterns
was not determined in this study. Overall, regardless of
the indication for arthroplasty, Vancouver classification
fracture patterns in either stem type were similar. Add-
itionally, it was not the objective of this study to determine
the incidence of periprosthetic fracture in cemented or
uncemented stems; therefore, it was not determined for
example that patients receiving cemented stems for the
neck of femur fractures were at increased risk of peripros-
thetic fracture compared to patients receiving uncemented
Page 6 of 7
stems for osteoarthritis. There was a lack of standard-
isation of plain films performed, with a variable quality
of imaging obtained reflecting the nature of imaging in
an elderly injured population. Interpretation of a classi-
fication system is subject to inter- and intra-observer
variability, and this was not formally assessed as intra-
operative findings were factored into the determination
of classification.
Conclusions
Periprosthetic fracture types according to the Vancouver
classification system occur in equal rates in cemented and
uncemented stems. The rates of stable and unstable stems
after fracture are therefore equal in both groups. Recogni-
tion of four distinct Vancouver B2 fracture patterns, in-
cluding the newly observed reverse clamshell pattern, will
aid surgeons in recognising stem instability. Future studies
investigating the association of fracture patterns with
treatment strategies are required to determine the clinical
significance of the findings of this study.
Abbreviations
CI: Confidence interval; SD: Standard deviation
Acknowledgements
Sarah-Jane Michael – graphic designs of periprosthetic fracture patterns.
Authors’ contributions
JK designed the study, collected data, performed the statistical analysis and
wrote the manuscript. PC and SD contributed to data collection. MH
provided the senior supervision. The author(s) read and approved the final
manuscript.
Funding
The authors declare that no funding was received for this study.
Availability of data and materials
The datasets used and analysed during the current study are available from
the corresponding author on reasonable request.
Ethics approval and consent to participate
This study was given ethics approval by the Central Coast Local Health
District Research Board. Informed consent was not required for this study.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Received: 21 December 2019 Accepted: 27 February 2020
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